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Application for Employer Identification Number Form SS-4 EIN

(Rev. January 2010) (For use by employers, corporations, partnerships, trusts, estates, churches,government agencies, Indian tribal entities, certain individuals, and others.)

OMB No. 1545-0003

Department of the TreasuryInternal Revenue Service

Legal name of entity (or individual) for whom the EIN is being requested

1

Executor, administrator, trustee, “care of” name

3

Trade name of business (if different from name on line 1)

2

Mailing address (room, apt., suite no. and street, or P.O. box)

4a

Street address (if different) (Do not enter a P.O. box.)

5a

City, state, and ZIP code (if foreign, see instructions)

4b

City, state, and ZIP code (if foreign, see instructions)

5b

County and state where principal business is located

6

Name of responsible party

7a

Estate (SSN of decedent)

Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.

9a

Partnership

Plan administrator (TIN)

Sole proprietor (SSN)

Farmers’ cooperative

Corporation (enter form number to be filed) ©

Personal service corporation

REMIC

Church or church-controlled organization

National Guard

Trust (TIN of grantor)

Group Exemption Number (GEN) if any ©

Other nonprofit organization (specify) ©

Other (specify) ©

9b

If a corporation, name the state or foreign country(if applicable) where incorporated

Changed type of organization (specify new type) ©

Reason for applying (check only one box)

10

Purchased going business

Started new business (specify type) ©

Hired employees (Check the box and see line 13.)

Created a trust (specify type) ©

Created a pension plan (specify type) ©

Banking purpose (specify purpose) ©

Other (specify) ©

12

11

Closing month of accounting year

Date business started or acquired (month, day, year). See instructions.

15 First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid tononresident alien (month, day, year) ©

Household

Agricultural

13 Highest number of employees expected in the next 12 months (enter -0- if none).

17 Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

18 Has the applicant entity shown on line 1 ever applied for and received an EIN? Yes No

Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.

Designee’s telephone number (include area code)

Date ©

Signature ©

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form SS-4 (Rev. 1-2010)

Typ

e o

r p

rint

cle

arly

.

Cat. No. 16055N

Foreign country

State

Designee’s fax number (include area code)

© See separate instructions for each line.

( )

( )

© Keep a copy for your records.

Compliance with IRS withholding regulations

SSN, ITIN, or EIN

7b

Other

Applicant’s telephone number (include area code)

Applicant’s fax number (include area code)

( )

( )

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

Name and title (type or print clearly) ©

ThirdPartyDesignee

Designee’s name

Address and ZIP code

Federal government/military Indian tribal governments/enterprises

State/local government

If you expect your employment tax liability to be $1,000or less in a full calendar year and want to file Form 944annually instead of Forms 941 quarterly, check here.(Your employment tax liability generally will be $1,000or less if you expect to pay $4,000 or less in totalwages.) If you do not check this box, you must fileForm 941 for every quarter.

Is this application for a limited liability company (LLC) (or a foreign equivalent)?

No

Yes

8a

If 8a is “Yes,” enter the number ofLLC members ©

8b

If 8a is “Yes,” was the LLC organized in the United States?

8c

No

Yes

14

Check one box that best describes the principal activity of your business.

16 Construction Real estate

Rental & leasing Manufacturing

Transportation & warehousing Finance & insurance

Health care & social assistance Accommodation & food service Other (specify)

Wholesale-agent/broker Wholesale-other

Retail

If “Yes,” write previous EIN here ©

If no employees expected, skip line 14.

Agent Staff: Alexander Wilkinson, Judith Garbati, and Linda Francois

HHCSR Using Fiscal/Employer Agent

✔

December


✔

617

617 889-5736

✔

,

C/O Public Partnerships LLC- GA DDW, 6 Admirals Way, Chelsea, MA 02150

✔

336-2900


6 Admirals Way

Public Partnerships LLC- GA DDW


Chelsea, MA 02150

✔

3

Form 2678(Rev. October 2012)

Employer/Payer Appointment of AgentDepartment of the Treasury — Internal Revenue Service

OMB No. 1545-0748

Use this form if you want to request approval to have an agent file returns and make deposits or payments of employment or other withholding taxes or if you want to revoke an existing appointment.

• If you are an employer or payer who wants to request approval, complete Parts 1 and 2 and sign Part 2. Then give it to the agent. Have the agent complete Part 3 and sign it.

Note. This appointment is not effective until we approve your request. See the instructions for filing Form 2678 on page 3.

• If you are an employer, payer, or agent who wants to revoke an existing appointment, complete all three parts. In this case, only one signature is required.

For IRS use:

Part 1: Why you are filing this form... (Check one)

You want to appoint an agent for tax reporting, depositing, and paying. You want to revoke an existing appointment.

Part 2: Employer or Payer Information: Complete this part if you want to appoint an agent or revoke an appointment.

1 Employer identification number (EIN) —

2 Employer’s or payer’s name (not your trade name)

3 Trade name (if any)

4 Address

Number Street Suite or room number

City State ZIP code

5 Forms for which you want to appoint an agent or revoke the agent’s appointment to file. For ALL

employees/ payees

For SOME employees/

payees (Check all that apply.)

Form 940, 940-PR (Employer's Annual Federal Unemployment (FUTA) Tax Return)*Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return) Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural Employees) Form 944, 944(SP) (Employer’s ANNUAL Federal Tax Return) Form 945 (Annual Return of Withheld Federal Income Tax) Form CT-1 (Employer’s Annual Railroad Retirement Tax Return) Form CT-2 (Employee Representative's Quarterly Railroad Tax Return)

*Generally you cannot appoint an agent to report, deposit, and pay taxes reported on Form 940, Employer's Annual Federal Unemployment (FUTA) Tax Return, unless you are a home care service recipient.

Check here if you are a home care service recipient, and you want to appoint the agent to report, deposit, and pay FUTA taxes for you. See the instructions.

I am authorizing the IRS to disclose otherwise confidential tax information to the agent relating to the authority granted under this appointment, including disclosures required to process Form 2678. The agent may contract with a third party, such as a reporting agent or certified public accountant, to prepare or file the returns covered by this appointment, or to make any required deposits and payments. Such contract may authorize the IRS to disclose confidential tax information of the employer/payer and agent to such third party. If a third party fails to file the returns or make the deposits and payments, the agent and employer/payer remain liable.

✗ Sign your name here

Date / /

Print your name here

Print your title here

Best daytime phone

Now give this form to the agent to complete. ■▶

For Paperwork Reduction Act Notice, see the instructions. IRS.gov/form2678 Cat. No. 18770D Form 2678 (Rev. 10-2012)

Form 2848(Rev. March 2012) Department of the Treasury Internal Revenue Service

Power of Attorney and Declaration of Representative

▶ Type or print. ▶ See the separate instructions.

OMB No. 1545-0150

For IRS Use Only

Received by:

Name

Telephone

Function

Date / /

Part I Power of Attorney Caution: A separate Form 2848 should be completed for each taxpayer. Form 2848 will not be honored for any purpose other than representation before the IRS.

1 Taxpayer information. Taxpayer must sign and date this form on page 2, line 7.

Taxpayer name and address Taxpayer identification number(s)

Daytime telephone number Plan number (if applicable)

hereby appoints the following representative(s) as attorney(s)-in-fact:

2 Representative(s) must sign and date this form on page 2, Part II.

Name and address

Check if to be sent notices and communications

CAF No.

PTIN

Telephone No.

Fax No. Check if new: Address Telephone No. Fax No.

Name and address

Check if to be sent notices and communications

CAF No.

PTIN

Telephone No.


Name and address CAF No.

PTIN

Telephone No.


to represent the taxpayer before the Internal Revenue Service for the following matters: 3 Matters

Description of Matter (Income, Employment, Payroll, Excise, Estate, Gift, Whistleblower, Practitioner Discipline, PLR, FOIA, Civil Penalty, etc.) (see instructions for line 3)

Tax Form Number (1040, 941, 720, etc.) (if applicable)

Year(s) or Period(s) (if applicable) (see instructions for line 3)

4 Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded on CAF, check this box. See the instructions for Line 4. Specific Uses Not Recorded on CAF . . . . . . . . . . . . . . ▶

5 Acts authorized. Unless otherwise provided below, the representatives generally are authorized to receive and inspect confidential tax information and to perform any and all acts that I can perform with respect to the tax matters described on line 3, for example, the authority to sign any agreements, consents, or other documents. The representative(s), however, is (are) not authorized to receive or negotiate any amounts paid to the client in connection with this representation (including refunds by either electronic means or paper checks). Additionally, unless the appropriate box(es) below are checked, the representative(s) is (are) not authorized to execute a request for disclosure of tax returns or return information to a third party, substitute another representative or add additional representatives, or sign certain tax returns.

Disclosure to third parties; Substitute or add representative(s); Signing a return;

Other acts authorized:

(see instructions for more information)

Exceptions. An unenrolled return preparer cannot sign any document for a taxpayer and may only represent taxpayers in limited situations. An enrolled actuary may only represent taxpayers to the extent provided in section 10.3(d) of Treasury Department Circular No. 230 (Circular 230). An enrolled retirement plan agent may only represent taxpayers to the extent provided in section 10.3(e) of Circular 230. A registered tax return preparer may only represent taxpayers to the extent provided in section 10.3(f) of Circular 230. See the line 5 instructions for restrictions on tax matters partners. In most cases, the student practitioner’s (level k) authority is limited (for example, they may only practice under the supervision of another practitioner).

List any specific deletions to the acts otherwise authorized in this power of attorney:

For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Cat. No. 11980J Form 2848 (Rev. 3-2012)

Form 2848 (Rev. 3-2012) Page 2

6 Retention/revocation of prior power(s) of attorney. The filing of this power of attorney automatically revokes all earlier power(s) of attorney on file with the Internal Revenue Service for the same matters and years or periods covered by this document. If you do not want to revoke a prior power of attorney, check here . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

7 Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, the husband and wife must each file a separate power of attorney even if the same representative(s) is (are) being appointed. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.

▶ IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED TO THE TAXPAYER.

Signature Date Title (if applicable)

Print Name PIN Number Print name of taxpayer from line 1 if other than individual

Part II Declaration of Representative Under penalties of perjury, I declare that:

• I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

• I am aware of regulations contained in Circular 230 (31 CFR, Part 10), as amended, concerning practice before the Internal Revenue Service;

• I am authorized to represent the taxpayer identified in Part I for the matter(s) specified there; and

• I am one of the following:

a Attorney—a member in good standing of the bar of the highest court of the jurisdiction shown below.

b Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.

c Enrolled Agent—enrolled as an agent under the requirements of Circular 230.

d Officer—a bona fide officer of the taxpayer’s organization.

e Full-Time Employee—a full-time employee of the taxpayer.

f Family Member—a member of the taxpayer’s immediate family (for example, spouse, parent, child, grandparent, grandchild, step-parent, step-child, brother, or sister).

g Enrolled Actuary—enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority to practice before the Internal Revenue Service is limited by section 10.3(d) of Circular 230).

h Unenrolled Return Preparer—Your authority to practice before the Internal Revenue Service is limited. You must have been eligible to sign the return under examination and have signed the return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled return preparers in the instructions.

i Registered Tax Return Preparer—registered as a tax return preparer under the requirements of section 10.4 of Circular 230. Your authority to practice before the Internal Revenue Service is limited. You must have been eligible to sign the return under examination and have signed the return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled return preparers in the instructions.

k Student Attorney or CPA—receives permission to practice before the IRS by virtue of his/her status as a law, business, or accounting student working in LITC or STCP under section 10.7(d) of Circular 230. See instructions for Part II for additional information and requirements.

r Enrolled Retirement Plan Agent—enrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice before the Internal Revenue Service is limited by section 10.3(e)).

▶ IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN LINE 2 ABOVE. See the instructions for Part II.

Note: For designations d-f, enter your title, position, or relationship to the taxpayer in the "Licensing jurisdiction" column. See the instructions for Part II for more information.

Designation—Insert above letter (a–r)

Licensing jurisdiction (state) or other

licensing authority (if applicable)

Bar, license, certification, registration, or

enrollment number (if applicable). See

instructions for Part II for more information.

Signature Date

Form 2848 (Rev. 3-2012)

Form 8821 OMB No. 1545-1165

Tax Information Authorization (Rev. August 2008)

Department of the TreasuryInternal Revenue Service

Employer identification number Social security number(s)

3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS forthe tax matters listed on this line. Do not use Form 8821 to request copies of tax returns. (a)

Type of Tax(Income, Employment, Excise, etc.)

or Civil Penalty

(b)Tax Form Number

(1040, 941, 720, etc.)

(c)Year(s) or Period(s)

(see the instructions for line 3)

Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6 ©

4

Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):

5 a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing

basis, check this box ©

b If you do not want any copies of notices or communications sent to your appointee, check this box ©

Retention/revocation of tax information authorizations. This tax information authorization automatically revokes allprior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect and check this box ©

6

7

Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by acorporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certifythat I have the authority to execute this form with respect to the tax matters/periods on line 3 above.

© Do not use this form to request a copy or transcript of your tax return. Instead, use Form 4506 or Form 4506-T.

Title (if applicable)

Date Signature

Print Name

Form 8821 (Rev. 8-2008) Cat. No. 11596P

For IRS Use Only

Telephone

Function

Date

/

/

Name

( )

Received by:

(d)Specific Tax Matters (see instr.)

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Title (if applicable)

Date Signature

Print Name

To revoke this tax information authorization, see the instructions on page 4.

Taxpayer information. Taxpayer(s) must sign and date this form on line 7.

1 Taxpayer name(s) and address (type or print)

Plan number (if applicable)

Daytime telephone number

Appointee. If you wish to name more than one appointee, attach a list to this form.

2 CAF No.

Name and address Telephone No.

Fax No. Telephone No.

Check if new: Address

( )

PIN number for electronic signature

Fax No.

© IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

© Do not sign this form unless all applicable lines have been completed.

© DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

PIN number for electronic signature

Employment

Quarters 1, 2, 3, 4 in 2011-2014

✔

,

SS-4,2678,2848,8821,8822

940,941,941X,W2,W2(c)

Household Employer

See attached document

Employment

Quarters 1, 2, 3, 4 in 2011-2014

Quarters 1, 2, 3, 4 in 2011-2014

617-889-5736617-336-2900

W-3,W-3(c),1096,1099

Other

Appointees

CAF No.Name and address (please type or print)

Telephone No.Fax No.

Telephone No.


Appointees



Telephone No.


Appointees



Telephone No.


Form 8821 Attachment of Appointed Representitives

Tax Information AuthorizationAttached List of Appointees

7. HAVE YOU...

Acquired another business? Yes No

Merged with another business? Yes No

Formed a corporation orpartnership? Yes No

Made any other change in theownership of your business? Yes No If yes, explain

GEORGIA DEPARTMENT OF LABORSUITE 850 - 148 ANDREW YOUNG INTERNATIONAL BLVD NE - ATLANTA, GA 30303-1751

EMPLOYER STATUS REPORT

READ INSTRUCTIONS ON REVERSE SIDEBEFORE COMPLETION OF FORM

1. ENTER OR CORRECT BUSINESS NAME AND ADDRESS

RETURN ORIGINAL WITHIN 10 DAYS

GEORGIA DOLACCOUNT NUMBER(If already assigned)2. TYPE OF ORGANIZATION

Individual Partnership Corporation Nonprofit org.

Limited Liability CO. (LLC)

Other (specify)

3. TRADE NAME

4. PRINCIPAL BUSINESS,FARM ORHOUSEHOLDLOCATION INGEORGIA(Do not use aP. O. Box number)

Street Address

City Zip Code County Telephone Number

5. DATE FIRST BEGANEMPLOYING WORKERSWITHIN STATE OF GA.

DATE OFFIRST GA.PAYROLL

6. ARE YOU LIABLEFOR FEDERALUNEMPLOYMENT TAX?

FEDERALI.D.NUMBER

DATE ACQUIREDOR CHANGED

PREDECESSOR’SGEORGIA DOLACCOUNT NUMBER

DOES THE FORMER OWNERCONTINUE TOHAVE EMPLOYEES?

DID YOU ACQUIRE...

All of Georgia operations?

Substantially all of Georgia operations(90% or more)

Part of Georgia operations (less than 90%)

GA

FROM WHOM? (Organization name, including trade name) ADDRESS

8. IF YOU HAD PRIVATE BUSINESS EMPLOYMENT:Did you, or do you expect to employ at least one workerin 20 different calendar weeks during a calendar year? Yes * No

* If yes, show date the 20th week first occurred:

Did you, or do you expect to have aquarterly payroll of $1,500 or more? Yes * No

* If yes, show date this first occurred:

11. IF YOU ARE A NONPROFIT ORGANIZATION EXEMPTFROM INCOME TAX UNDER IRS CODE 501(C)(3): Yes * NoDid you, or do you expect to employ four or moreworkers in 20 different calendar weeks during acalendar year? (ATTACH COPY OF 501(C)(3) EXEMPTION LETTER)


9. IF YOU HAD DOMESTIC EMPLOYMENT:Did you, or do you expect to pay cash wagesof $1,000 or more in any calendar quarter? Yes* No


10.IF YOU HAD AGRICULTURAL EMPLOYMENT: Yes* NoDid you, or do you expect to employ 10 or more agriculturalworkers in 20 different calendar weeks during a calendar year?


Did you, or do you expect to have a gross cash agriculturalpayroll of $20,000 or more in any calendar quarter? Yes* No


12.HOW MANY EMPLOYEES do you have, (or anticipatewhen in full operation)?

INFORMATIONABOUTOWNER,ALLPARTNERS,OR PRINCIPALOFFICER(ATTACHADDITIONALSHEET,ORSHEETS, IFNECESSARY)

INFORMATIONABOUTPERSONOR FIRMWHOMAINTAINSFINANCIALRECORDSOF BUSINESS

Name

Social SecurityNumber

Residence Address

City

State Zip Code

Telephone( )

CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those containedin any attached sheets signed by me are true and correct, and that I am authorized to execute this report onbehalf of the employing unit. This report must be signed by owner, partner or principal officer.

Signature Title Date

Name

Address

City

State Zip Code Telephone( )

PLEASE COMPLETE INDUSTRY INFORMATION ON REVERSE SIDE. DOL-1A (R-5/05)TA489A

( )

Yes No

Yes No

6 Admirals Way

MA 617

✔

✔

c/o Public Partnerships, LLC - GA DDD6 Admirals WayChelsea, MA 02150

Household Employer

✔

✔

Public Partnerships, LLC - GA DDD

02150 336-2900

✔

Chelsea

✔

✔

(CONTINUED)

NATURE OF BUSINESS: Information is required on all items. Attach additional sheets, if necessary.

A. How many Georgia locations do you operate?Provide the following information for each location, attaching additionalsheets if necessary.

B. Check the box that best describes the industry that relates to yourbusiness activities:

Agriculture ManufacturingForestry TransportationFishing CommunicationMining Public UtilitiesConstruction (specify): Wholesale TradeGeneral Contractors Industrial % Retail TradeResidential % Commercial % FinanceSpeculative Building InsuranceSpecial Trade Contractor (specify plumbing, Real Estateetc.,) ServicesHeavy Construction (specify cable, highway, Public Administrationetc.,) Private Household

Employer

C. Enter in order of importance and indicateapproximate % of total annual income derivedfrom each:

Principal Service(s) Principal Product(s)Rendered* Mfg. Grown Sold

* If Transportation - Trucking, indicate if interstate carrier

D. If this report includes establishment(s) that onlyperform services for other units of the company,indicate the primary type of service or supportprovided. Check as many as apply:

1. Central Administration 3. Storage (warehouse)2. Research, development, 4. Other: (specify)

and testing

FOR ASSISTANCE, call the Industry Classification Unit, (800) 338-2082

IMPORTANT - This report must be filed! The law provides that all employing units shall file a report of its employment during a calendar year. For the purposeof aiding you in complying with OCGA Section 34-8-121 of the Employment Security law, this form has been prepared to assist you in furnishing the requiredinformation. Answer all questions fully and if additional space is necessary under any item, attach signed and dated sheets which bear the words Supplementto Form DOL-1.”

Each false statement or willful failure to furnish this report is punishable as a crime. Each day of such failure or refusal constitutes a separate offense.

The Georgia Employer Status Report is required of all employers having individuals performing services in Georgia regardless of number or duration of time.

The filing of this form is required at the time your business first had individuals performing service in Georgia, or when you acquired another legal entity, andmay also be required again upon request.

NOTE: Disclosure of your social security number is mandatory. It will be used for the purpose of identification and it is required under the authority of42 U.S.C. Section 405(2)(c) and OCGA Section 34-8-121(a).

INSTRUCTIONS(NUMBERS CORRESPOND TO ITEMS ON FORM)

1. Enter or correct name and address of individual owner, partners, corporation or organization. This is the address to which you authorize us to mail allreports, correspondence, etc. If you have already been assigned a Georgia Department of Labor Account Number (Ga. DOL Acct. No) by thisDepartment, please insert the number.

2. Indicate by check mark type of organization. If a nonprofit organization, attach copy of I.R.S. letter exempting the organization from Federal IncomeTax under Section 501(c)(3)of Internal Revenue Code.

3. Trade name by which business is known if different than 1.4. Physical location of business, farm or household in Georgia if different than 1. Please include telephone number with area code.5. Enter the first date of employment in Georgia and the first date of Georgia payroll.6. If you are subject to the Federal Unemployment Tax Act, and are required to file Federal Form 940, answer this question “yes”. Be sure to enter your

Federal Employer Identification Number whether answered “yes” or “no”.7. Answer this question if you acquired this business from another employer or if after you began employing workers you have acquired other busi-

nesses; merged with other businesses; formed or dissolved partnerships, corporations, professional associations; or if any other change in theownership of the business has occurred. Indicate the date of acquisition or change and provide all information concerning the previous owner’s name,trade name, address and DOL Account Number. Indicate by checking the appropriate block the portion of the previous owner’s business involved inthe acquisition or change. No transfer of experience rating history can be made unless information concerning the previous owner is provided.

8. Private Business Employment - Most employment is considered private business employment. This includes all types of work except domesticservice such as maids, gardeners, cooks, etc., agricultural service and service performed for governmental or nonprofit organizations.

9. Domestic employment includes all service for a person in the operation and maintenance of a private household, local college club or local chapter ofa college fraternity or sorority such as chauffeurs, cooks, babysitters, gardeners, maids, butlers, private and/or social secretaries, etc. If you had suchemployment, consider only cash payments made to all individuals performing domestic services to determine if $1,000 or more cash wages were paidin any calendar quarter during 1977 and subsequent quarters.

10. Consider only cash payments made to all individuals performing agricultural services to determine if $20,000 or more cash wages were paid in anycalendar quarter during 1977 and subsequent quarters.

11. Answer this question only if this business is a nonprofit organization exempt from Federal Income Tax under Section 501(c)(3) of the Internal RevenueCode. Attach a copy of the I.R.S. letter granting this exemption. Nonprofit organizations with tax exemptions other than under Section 501(c)(3)should answer question 8, Private Business Employment.

12. Self-explanatory.

OR

Please RETAIN a copy for your files.

The enclosed envelope requires postage.

RETURN ORIGINAL WITHIN TEN (10) DAYS TO: Georgia Department of LaborP. O. Box 740234Atlanta, GA 30374-0234

FOR ASSISTANCE, call the Adjudication Section, (404) 232-3301.

%%%

✔

Hire employees to provide in-home care services

Georgia Department of Revenue Power of Attorney and Declaration of Representative Submit this form through GTC (gtc.dor.ga.gov) or to the Department employee handling your inquiry.

Form RD-1061 (Rev. 09/20/18)

The representative is authorized to represent the taxpayer before the Department for the following tax matters: Tax Type(s): Tax Period(s) or Tax Year(s): The representative is authorized to perform on behalf of the taxpayer the following act(s) for the tax type(s) and tax period(s) or year(s) above (check all that apply):

To make payments on behalf of the taxpayer. To receive, but not to endorse and collect, checks in payment of any refund of tax, penalty or interest.

To execute waivers (and related documents) of restrictions on assessment or collection of tax deficiencies and waivers of any other rights of taxpayer.

To execute consents extending the statutory period for assessment, collection or refund of taxes. To file protests and appeals from notices of assessment and to represent taxpayer in conferences and hearings. To execute claims for refund. To receive confidential information pertaining to these tax matters. To perform all other lawful acts on behalf of the taxpayer concerning the tax matters above.

Section 1 Taxpayer Information Taxpayer’s Name SSN/FEIN Telephone Number

Spouse’s Name (if joint income tax return) Spouse’s SSN (if applicable) Telephone Number (if applicable)

Mailing Address

Spouse’s Mailing Address (if different from above)

Section 2 Representative Information Name of Person Given Power of Attorney Telephone Number Email Address

Mailing Address

Name of Person Given Power of Attorney Telephone Number Email Address

Mailing Address

Section 3 Tax Matters

Section 4 Retention/Revocation of Prior Power(s) of Attorney The filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Georgia Department of Revenue for the same matters and years or periods covered by this document. If you DO NOT want to revoke a prior Power of Attorney, mark an X in this box. Please specify which Power(s) of Attorney you wish to remain in effect by listing the authorized representative(s) below:

Section 5 Taxpayer Authorization and Signatures

• The taxpayer named in Section 1 appoints the individual(s) named in Section 2 as representative(s) for the taxpayer concerning the tax matter(s) listed in Section 3.

• The taxpayer acknowledges that it is his or her responsibility to keep the representative(s) listed in Section 2 informed of the tax matters involving the Department and that the Department is not able to send copies of correspondence directly to the representative(s).

This Power of Attorney is not valid until it is signed and dated. If signed by a corporate officer, partner, member, trustee, or executor/ executrix on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer. I understand that to willfully prepare or present a document that is fraudulent or false is a felony under O.C.G.A. § 16-10-20.

Signature Print Name Date Title (if corporate officer)

Spouse’s Signature (if joint) Print Spouse’s Name Date

Page 1

Form RD-1061 (Rev. 8/18) Form RD-1061 (Rev. 09/20/18)

Section 6 Acknowledgment of the Power of Attorney This Power of Attorney must be acknowledged by the taxpayer before a notary public, unless the appointed representative(s) is licensed to practice as an attorney-at-law, certified public accountant, registered public accountant, or is enrolled as an agent to practice before the Internal Revenue Service. If the appointed representative(s) is licensed to practice as an attorney-at-law, certified public accountant, registered public accountant, or is enrolled as an agent to practice before the Internal Revenue Service, skip Section 6 and continue to Section 7.

Acknowledgement of Power of Attorney. The person(s) signing as the taxpayer in Section 5 above appeared this day before a notary public and acknowledged this Power of Attorney as a voluntary act and deed.

Sworn and subscribed before me this __________ day of ______________________, 20_______.

Signature of Notary Date

Section 7 Declaration of Representative Under penalties of perjury, I declare that: • I am authorized to represent the taxpayer identified in Section 1 for the matter(s) specified in Section 3 of this form; and • I am one of the following (indicate all that apply):

1. An attorney-at-law licensed to practice in and a member in good standing of the Bar of the jurisdiction indicated below. 2. A certified public accountant duly qualified to practice in the jurisdiction indicated below. 3. Enrolled as an agent to practice before the Internal Revenue Service under the requirements of Circular 230. 4. A registered public accountant.

Designation –

use number(s) from above list

(1 - 4)

Licensing jurisdiction (state) or other

licensing authority (if applicable) Bar, license, certification,

registration, or enrollment number Signature Date

Notary Seal


Purpose of Form A taxpayer may use Form RD-1061 to authorize an individual or individuals to represent the taxpayer before the Georgia Department of Revenue, to discuss and/or access confidential information, and to perform certain acts on behalf of the taxpayer for certain tax matters and periods. This Power of Attorney (POA) only authorizes the listed representative(s) to perform the acts indicated in this Form RD-1061. Representatives are not authorized to endorse or otherwise negotiate any check (including accepting payment by any means) issued by the Department. However, the representative(s) may make payments on behalf of the taxpayer if specifically authorized on the Form RD-1061.

Filing Instructions Taxpayers should submit Form RD-1061 by uploading through Georgia Tax Center (GTC) (gtc.dor.ga.gov) or by sending to the Department employee handling your inquiry. To upload to GTC: (1) Login, (2) Under “I Want To” select “See More Links”, (3) Select “Submit Power of Attorney", and (4) Follow the prompts to upload the Form RD-1061. Revocation If you have a valid Form RD-1061 on file with the Department, the filing of a new Form RD-1061 revokes the authority of the prior representative for the same matters and periods covered by the new Form RD-1061 unless Section 4 is completed. The prior representative is still an authorized representative and retains any previously granted authority for the matters and periods not covered by the new Form RD-1061 unless specifically revoked. If the taxpayer or representative merely wants to revoke an existing authorization, upload a copy of the previously executed Form RD-1061 on GTC with “REVOKE” clearly written on the form. If you do not have a copy of the authorization you want to revoke, upload a statement of revocation to GTC. The statement of revocation must indicate the name of each representative whose authority is revoked. To upload a revocation on GTC follow the same steps outlined above. Specific Instructions Section 1 – Taxpayer Information Enter the name, address, and contact information of the taxpayer. If the taxpayer is an individual, enter the full Social Security number (SSN). If the taxpayer is a business entity, enter the Federal Employer Identification Number (FEIN). If the taxpayer is granting access to a joint return, enter the spouse’s name, address, and full SSN. Section 2 – Representative Information Enter the representatives’ names, addresses and any applicable contact information. A representative must be an individual, not a business entity. If designating authority to more than two representatives, please attach a schedule similar in form to Section 2 signed by the taxpayer. Section 3 – Tax Matters Enter the tax type(s) and specific period(s) or year(s) for which the authorization is being granted. The Department will only discuss and/or disclose taxpayer information for the type(s) and period(s) listed. Notices and communications will be sent to the taxpayer, not the representative. The representative may access copies of taxpayer notices and communications via third party access to the taxpayer’s account through GTC.


Section 4 – Retention/Revocation of Prior Power(s) of Attorney All existing Form RD-1061s effective for the same matters and periods covered by this document previously filed by the taxpayer will be revoked unless the taxpayer checks the box on this line. If the taxpayer checks this box, the taxpayer must list the representative(s) previously authorized whose Form RD-1061 they wish to remain in effect. If you check the box, but do not specify a previously authorized representative, all existing Form RD-1061s will remain in effect. Section 5 – Taxpayer Authorization and Signature The taxpayer must sign in Section 5 for Form RD-1061 to be effective. The table below shows who should sign for each type of taxpayer:

Taxpayer Who Must Sign

Individuals The individual/sole proprietor must sign (if granting access to a joint return, spouse must also sign).

Corporations A corporate officer with authority to sign. Partnerships A partner having authority to act in the name of the partnership must sign. Limited Liability Companies A member having authority to act in the name of the company must sign.

Trusts A trustee must sign. Estates An executor/executrix or the personal representative of the estate must sign.

Section 6 – Acknowledgment of the Power of Attorney This POA must be acknowledged by the taxpayer before a notary public, unless an appointed representative is an attorney-at-law, certified public accountant, registered public accountant, or is enrolled as an agent to practice before the Internal Revenue Service. If an appointed representative is an attorney-at-law, certified public accountant, registered public accountant, or is enrolled as an agent to practice before the Internal Revenue Service, then Section 7 should be filled out completely instead of Section 6, which may be left blank.

Section 7 – Declaration of Representative If an appointed representative is licensed to practice as an attorney-at-law, certified public accountant, registered public accountant, or is enrolled as an agent to practice before the Internal Revenue Service, then they may fill out Section 7 in lieu of being acknowledged by a public notary in Section 6.

RD-1062 (Rev. 7/14)

Disclosure Authorization Form Print or Type

Enter only those that apply Federal Employer ID No.

Social Security No.

Georgia State Tax ID No.

1. Taxpayer Information Taxpayer(s) name(s) and address

Georgia Sales Tax Registration No.

Daytime Telephone Number Georgia Withholding Tax No.

Provide one of the following identification numbersState and State Attorney Bar Number

Social Security or other identification number (for other ID provide number and type)

2. Appointee Information Appointee name and address

Daytime Telephone Number State and Certified Public Accountant Number

3. Tax Matters. The appointee is authorized to receive confidential information for the tax matter listed below: Tax Type Year(s) or Period (s)

Personal Income Tax....................................................... Sales and Use Tax ..........................................................

Corporate Income Tax..................................................... Withholding Tax............................................................... Other (specify)

4. Revocation of Earlier Authorization(s). This disclosure authorization form does not revoke any prior

(please specify):

5. Signature of or for the Taxpayer. I hereby certify that the Georgia Department of Revenue is authorized to

Signature: Date:

Print Name: Title (if applicable): The person signing as or for the taxpayer appeared this day before a notary public and acknowledged this disclosure authorization form as a voluntary act or deed.

Signature of Notary Date NOTARY SEAL

1

(Submit this form to the Department Division which is handling your inquiry)

authorization forms on file with the Department unless the following box is checked: If the box is checked,the revocation will be effective as to all earlier authorizations of file with the Department of Revenue except

disclose and/or discuss confidential information or records concerning the undersigned taxpayer to the appointeenamed above for the tax type(s) and period(s) named above. If signed by a corporate officer, member, partner,trustee or executor/executrix, I certify that I have the authority to execute this authorization form on behalf of the taxpayer. I understand that to willfully prepare or present a document that is fraudulent or false is a misdemeanor under O.C.G.A. § 48-1-6.

2

RD1062 Disclosure Authorization Form

Purpose of FormA taxpayer may use Form RD1062 to authorize the Georgia Department of Revenue to disclose and/or discuss confidential tax information for such taxpayer with an appointee for a specific tax type(s) and period(s). Form RD1062 cannot be used as a Power of Attorney and thus does not grant the appointee any powers of representation. Filing InstructionsTaxpayers should submit Form RD1062 to the appropriate taxing division. Taxpayers should only use this form whensubmitting a specific request for information.

Specific InstructionsSection 1 - Taxpayer Information Individuals - Enter your name, address, and any applicable identification numbers.

Section 2 - Appointee Enter the appointee's name, address, and any applicable identification numbers.

Section 3 - Authorization Enter the tax type(s) and specific period(s) or year(s) for which the authorization is granted. A general reference to "all years" or "all periods" is not acceptable. Section 4 - Retention/Revocation of Prior Disclosure Authorization Forms All existing disclosure authorization forms previously filed by the taxpayer will not be revoked unless the taxpayer checks the box on this line. If the taxpayer checks off this box but does not want to revoke all existing disclosure authorization forms, the taxpayer should either specify the forms that the department should retain or attach a copy of such existing form(s).

A taxpayer may revoke a disclosure authorization form without authorizing a new appointee by filing with the department either: (1) A statement of revocation signed by the taxpayer indicating that the authority of the previous disclosure authorization form is revoked along with the name and address of each appointee whose authority is revoked; or (2) A copy of the disclosure authorization form to be revoked clearly marked "REVOKED."

It is important to note that the filing of a Form RD1062 disclosure authorization form will not revoke any Power of Attorney that is in effect.

Section 5 - Signature of Taxpayer

Taxpayer Who must sign Individuals The individual/sole proprietor must sign. Corporations A corporate officer or a person designated by a corporate officer must sign. Partnerships A partner having authority to act in the name of the partnership must sign. Trusts A Trustee must sign. Estates An Executor/Executrix or the personal representative of the estate must sign. Limited Liability Companies A member having authority to act in the name of the company must sign.

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